Medical Scribe

Kaweah Delta Health Care District•Visalia, CA

20d•Onsite

About The Position

Performs clerical and information technology functions for a physician in a clinic and/or hospital setting. Primary responsibility is the capture of accurate transcribed documentation in the electronic medical record system. Primary goal is to increase patient and department throughput.

Requirements

High school diploma or equivalent
Medical terminology knowledge
Quick and accurate typing speed
Strong interpersonal and communication skills

Nice To Haves

Some pre-nursing and/or pre-med courses
Transcription in an electronic medical record system

Responsibilities

Accompanies physician into the patient examination room in order to accurately document the physician’s encounter with the patient and others present.
Responsible for accurate, timely charting of patient encounters, including but not limited to patient history, physical exams, diagnostic findings, lab and test results, consultations with other providers, treatment course, diagnoses, patient instructions, prescriptions and follow-up instructions.
Reviews the primary diagnoses with provider to ensure that all documentation is accurate and clinically supported in the EMR.
Per provider direction, enters proposed orders in the EMR that has accurate and complete diagnosis codes to support the order.
Prior to patient encounter, facilitates the acquisition of test results for the provider to review.
Continually checks the status of pending studies in order to increase department efficiency.
Documents any procedures performed by the physician.
Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area.
Performs other duties as assigned.